Health Plan Overview
- What does in-network coverage mean?
- In-network coverage means covered services that are either received:
- From a participating practitioner or provider;
- In an emergency medical condition or urgent care situation;
- When you do not have appropriate access to a participating practitioner and/or provider; or
- When a participating practitioner has recommended, and the Plan has certified the referral to, a non-participating practitioner and/or provider.
- What does out-of-network coverage mean?
- Out-of-network coverage means covered services that do not fit the definition of in-network coverage described above. Specifically, out-of-network coverage means covered services that you receive:
- From non-participating practitioners and/or providers when appropriate access to a participating practitioner and/or provider is available;
- For which the Plan has not certified the referral to a non-participating practitioner and/or provider; or
- For non-emergency or non-urgent care situation.
- What is a “formulary” and where can I find the drugs included?
- A formulary is a list which identifies those prescription drug products which are preferred by the medical insurance plan for dispensing to you when appropriate. The list is reviewed and modified each year. You can find a list of the formulary drug names in your enrollment booklet along with a description of pharmacy management procedures.
- What is a generic drug?
- A generic drug is a medication chemically equivalent to a Brand-name drug whose patent has expired. Generic drugs are typically $15 to $20 less per month than brand name drugs. You can get a generic drug by asking your physician or pharmacist if there is a generic form of the drug before you fill the prescription.
- What do I do if I need to see a specialist?
- Sanford Health Plan works with a large network of participating providers from nearly every medical specialty to give you direct access to the health care services you need. If the specialist is a participating provider with Sanford Health Plan, you may schedule an appointment and the office visit will be considered In-Network according to your plan benefits. If the specialist is NOT a participating provider, you must contact Sanford Health Plan to request authorization. If authorization is received, then the specialist will be considered In-Network. Please remember that the specialist may order additional diagnostic tests or additional medical care. Some services require prior authorization and your provider will need to use an In-Network facility. Failure to obtain prior authorization may result in reduced coverage to the specialty services.
- What is utilization review?
- Utilization review is used by the Utilization Management Department to monitor and evaluate the medical necessity, appropriateness, and efficacy of health care services, procedures and facilities.
There are 3 types of utilization reviews:
- Prior authorization (Prospective or preservice review): The urgent or non-urgent review of a requested service prior to receiving the service. The Plan determines approval for prior authorization based on appropriateness of care and service and existence of coverage.
- Concurrent review: Review conducted during a member’s hospital stay or course of treatment in a facility or other inpatient or outpatient healthcare setting.
- Retrospective review: Review of services that have already been utilized by the member.
- What is case management?
- Sanford Health Plan provides nurse case management services to insured members in order to assist in controlling healthcare costs and improve the overall health of our Members. The Case Manager involves all members of the healthcare team in the decision-making process in order to minimize fragmentation of the healthcare delivery system. The Case Manager is the link between the individual, the practitioners and/or providers, the payer and the community. The Case Manager encourages appropriate use of medical resources and monitors effectiveness on a case-by-case basis. The Case Manager is an advocate for the Member as well as the payer to facilitate a win-win situation for the patient, the healthcare team and the payer.
For individuals with more complex health needs, the Nurse Case Manager is a resource and advocate to assist members in understanding their condition and treatment plan. The Case Manager will work alongside the member to develop personalized goals and a self- management plan and to assist the member in feeling more in control of their health. The Case Manager will also work directly with the care team to ensure all needs are met.
- What doctors can I see with Sanford Health Plan?
To ensure you are receiving in-network benefit coverage, you are required to use the specific network tied to your plan. You can find participating providers here.